Doctors And Death

I just read an article that's worth reading by everyone. Titled How Doctors Die, it's ultimately about end of life care, futile care, making impossible decisions. And it evokes in me thoughts that I've had many times, in many ways.

The title comes from the writer's (a physician) claim (which he makes no attempt to document, by the way) that doctors tend not to opt for all the extraordinary, expensive, and odds-fighting care they often provide for their patients, preferring to go quietly. I've said many times -- and I hope it's true -- that my plan is to not get sick; and when I do, to have the wherewithal to take things in my own hands and never set foot in a hospital.

From the article:

Almost all medical professionals have seen what we call “futile care” being performed on people. ... All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

Then the article gets to the real point -- unreasonable expectations, impossible choices, insurmountable pressures:

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

[...]

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar.

As President Obama has discovered, this is an extraordinarily difficult subject, the perfect platform for political posturing. Ironically, it's the party that most loudly claims to want to cut Medicare spending that has taken the president's reasonable efforts to address this morass as an opportunity for demagoguery. Hard to imagine it addressed seriously. There's global climate change; the political climate shows no sign of cooling.

Mentioned in the article is a patient of the author who'd always made it clear he didn't want extraordinary measures. But then he had a massive stroke and was brought to an ER where no one knew him.

Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. (Emphasis mine.)

When it came time to withdraw care, I always felt the need to involve the nurses caring for the patient, to ask if any had reservations, and to discuss them. It wasn't as much ass-covering as it was acknowledgment that they'd invested more time and emotion in the patient than I had, and needed to be heard. But, yes, ass-covering was surely on my mind, too.

It shouldn't have to be. It ought to be possible, based on knowledge, compassion, data, patient wishes, and proper education of patients and potential patients, managing expectations, to provide comfort care only when it's the right thing. Not just possible: expected; part of the job; a no-brainer. As it were. Maybe, somewhere, in a society more rational than ours, it can be.